By Dr Gareth Kantor & Dr Michele Youngleson
No hospital in the world provides perfect care. We believe the best hospitals are those that strive continuously to improve and to make care safer.
The management of a large client South African hospital embraced this challenge. They agreed to work with us to develop better systems for learning about, and improving, patient safety in their facility. Our initial focus was on preventable mortality using what we call a Diagnostic Mortality Audit Process (DMAP)™.
The Stratification Matrix
Not all deaths in hospital are unexpected. Many are the predictable outcome of serious illness and/or occur at the end of a healthy life. Using an approach first described by the Institute for Healthcare Improvement1 our first step was to identify patients who were receiving palliative care before the time of death. These deaths in hospital may suggest problems in end of life care both in the hospital and in the community, as most patients given the choice prefer to die at home surrounded by loved ones2.
The second step was to identify patients admitted to the ICU. These deaths may identify opportunities to apply known and proven improvement techniques, such as for the prevention of line-related bloodstream infection or ventilator-associated pneumonia. Preventable deaths in general wards may point to other problems, with risk assessment and in the quality and reliability of ward level care1. For example, some deaths can be characterised as “failure to rescue”, the situation where signs of clinical deterioration, such as changes in heart rate, blood pressure or breathing, are unrecognised, or response is delayed. In these circumstances, an Early Warning Score that activates a Rapid Response Team3 is a useful intervention, helping to trigger additional monitoring, resuscitation, transfer to ICU and definitive treatment.
Mapping the patient journey
After separating the last 50 cases of mortality into recipients of palliative care, and ICU or non-ICU patients the hospital team, working in small groups, visually mapped each patient journey from pre-admission through the hospital to the point of death. This exercise makes it easier to identify and piece together relevant pre-hospital factors, entry points, investigations, procedures, wards and management, and resuscitation attempts that contributed to the final outcome.
At the same time, the team used our adaptation of the IHI Global Trigger Tool4 to flag specific occurrences in the patient journey that suggest risk. Triggers, such as an unplanned return to theatre, or use of the opioid reversal drug naloxone, were assessed during the team-based review of each patient’s folder. We also provided a “3 x 3 model” to identify harm that has occurred by omission or by commission. This model describes 3 kinds of delays, 3 types of defects and 3 failures. For reviewing resuscitations, we asked the team to pose three questions in each case: “What went well?”, “What could have gone better?”, and “What will we do differently next time?”
This comprehensive mortality audit approach helped the team to prioritise, through the initial stratification exercise, and to identify system factors associated with serious preventable harm in their hospital through a detailed drill-down view of each case.
During the subsequent four-month Action Period the team was tasked with
establishing the routine use of this model for mortality reviews to identify problems, understand the root causes of the problems and introduce changes to address the care gaps.
What did they learn?
The improvement team enthusiastically embraced these methods, allocating time each Friday afternoon in the subsequent four months for the group to review each case, and then to shift from retrospective audit to a closer to real-time review of cases for prompt action.
Within the 4-month Action Period, as a result of these reviews and application of the audit tools, the team identified a number of issues which they began to make the focus of their quality improvement (QI) program, and which quickly generated ideas for change. Issues and interventions included:
– Improved triage of trauma patients in casualty
– Better identification of at risk patients in casualty and wards
– Improving heart attack diagnosis and time to definitive management in the cardiac catheterisation lab
– Improving emergency skills such as intubation
– Innovative suggestions for mentoring of ER physicians by specialists
– Increasing the percentage of obstetrician-attended births
– Improving the timing and reliability of response to critical laboratory results.
The DMAP™ also revealed delays with insurance authorisation that could have harmed patients and created risk for the organisation. Expectations around the time within which a patient should be seen by the admitting surgeon or physician have been adjusted.
QI requires teamwork and is about change. This particular hospital has the asset of a strong and committed management team who work well together. They are focused on the success of their facility and safety of their patients and are empowered to make change, take decisions independently and act quickly.
Electronic data systems can play a vital role
QI also requires data. Our client hospital has the distinct advantage of a custom electronic information system that can be programmed for functionality as needed, for example to provide a list of recent deaths, with admission dates, length of stay, triggers and diagnoses.
Using this capability, they designed and introduced an innovative electronic “shift report” tool which prompts staff to identify triggers and provides the opportunity to comment, resulting in approximately 6,000 entries over the initial 6 weeks of use. The information is summarised in a table making it easy for the next shift and management to quickly identify at risk patients for attention. Anecdotally, it appears that patient satisfaction scores have improved in wards where the shift report has been readily adopted. This generalised intervention has the potential to reduce preventable harm across the hospital.
A safer hospital for patients – and a healthy organisational culture for staff and patients
The health services literature documents a consistent association between positive organisational cultures and clinical outcomes, including reduced mortality rates5. Elements of culture associated with success include: fostering a learning environment, offering sustained and visible senior management support to clinical teams and services, ensuring that staff across the organisation feel “psychologically safe” and able to speak up when things are felt to be going wrong.
We believe that the tools for learning about safety are helping to build this kind of culture at our client hospital and that this will contribute to greater safety and better outcomes. Both patients and staff will the beneficiaries of this initiative. We look forward to seeing the results – the data – and to helping other hospitals in South Africa to try this new approach.
To learn more about the Diagnostic Mortality Audit Process (DMAP)™, contact:
Dr Gareth Kantor
1. Institute for Healthcare Improvement. Reducing Hospital Mortality Rates.; 2009.
2. Gomes B, Calanzani N, Gysels M, Hall S, Higginson IJ. Heterogeneity and changes in preferences for dying at home: a systematic review. BMC Palliat Care. 2013;12(1):7. doi:10.1186/1472-684X-12-7.
3. Winters BD, Weaver SJ, Pfoh ER, Yang T, Pham JC, Dy SM. Rapid-Response Systems as a Patient Safety Strategy. Ann Intern Med. 2013;158(5_Part_2):417. doi:10.7326/0003-4819-158-5-201303051-00009.
4. Griffin F, Resar R. IHI Global Trigger Tool for Measuring Adverse Events.; 2009.
5. Mannion R, Smith J. Hospital culture and clinical performance: where next? BMJ Qual Saf. 2017;epub ahead(December):1-3. doi:10.1136/ bmjqs-2017-007668.